Labor and Economic Opportunity
The Explanation of Benefits (EOB) serves many purposes, including notifying the parties of reimbursement decisions, educating the injured worker regarding balance billing, and outlining the provider’s right to appeal payment adjustments.
Recently, we have seen an increase in the use of third-party medical cost-containment networks and payors within the workers’ compensation arena. It is important to note that Rule 117 (R 418.10117) of the Workers’ Compensation Health Care Services (HCS) rules states in part:
(4) A carrier or designated agent shall record payment decisions on a form entitled “The Carrier’s Explanation of Benefits” using a format approved by the agency. The carrier or designated agent shall keep a copy of the explanation of benefits and shall send a copy to the provider and to the injured worker. The carrier’s explanation of benefits shall list a clear reason for the payment adjustment or amount disputed and shall notify the provider what information is required for additional payment.
The rules allow carriers and providers to utilize these networks if they choose; however, it is important to reiterate that the carrier or its designated agent must send a copy of the EOB to the provider and to the injured worker. The HCS rules define a provider as a “facility, health care organization, or a practitioner.”
A third-party payor or network is not considered to be the provider. In the event that a third-party payor or network is utilized, they should not be listed as the provider. The carrier or its designated agent must send an agency-approved EOB form to the provider and the injured worker.
For additional reference, EOB requirements are outlined in R 418.10117, R 418.101001, R 418.101015, and R 418.101301.
Any questions regarding this matter may be directed to the HCS Division at 888-396-5041.